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Stereotypic Movement Disorder
DSM-III In DSM-III, this disorder is a category called Atypical Stereotyped Movement Disorder This category is for conditions such as head banging, rocking, repetitive hand movements consisting of quick, rhythmic, small hand rotations, or repetitive voluntary movements that typically involve the fingers or arms. These disorders are distinguishable from tics in that they consist of voluntary movements and are not spasmodic. Moreover, unlike individuals with a Tic Disorder, those with these conditions are not distressed by the symptoms and may even appear to derive enjoyment from the repetitive activities. Though bizarre posturing or movements may occur in adults, these conditions are found almost exclusively in children. They are especially prevalent among individuals with Mental Retardation or Pervasive Developmental Disorders and among children suffering from grossly inadequate social stimulation, but they may also occur in the absence of a concurrent mental disorder. DSM-IV Diagnostic Criteria A'''. Repetitive, seemingly driven, and nonfunctional motor behavior (e.g., hand shaking or waving, body rocking, head banging, mouthing of objects, self-biting, picking at skin or bodily orifices, hitting own body). '''B. The behavior markedly interferes with normal activities or results in self-inflicted bodily injury that requires medical treatment (or would result in an injury if preventive measures were not used). C'''. If Mental Retardation is present, the stereotypic or self-injurious behavior is of sufficient severity to become a focus of treatment. '''D. The behavior is not better accounted for by a compulsion (as in Obsessive-Compulsive Disorder), a tic (as in Tic Disorder), a stereotypy that is part of a Pervasive Developmental Disorder, or hair pulling (as in Trichotillomania). E'''. The behavior is not due to the direct physiological effects of a substance or a general medical condition. '''F. The behavior persists for 4 weeks or longer. Specify if: * With Self-Injurious Behavior: if the behavior results in bodily damage that requires specific treatment (or that would result in bodily damage if protective measures were not used) Specifiers The clinician may specify With Self-Injurious Behavior if the behavior results in bodily damage that requires specific treatment (or that would result in bodily damage if protective measures were not used). Differential Diagnosis Mental Retardation Stereotypic movements may be associated with Mental Retardation, especially for individuals in nonstimulating environments. Stereotypic Movement Disorder should be diagnosed only in individuals in whom the stereotypic or self-injurious behavior is of sufficient severity to become a focus of treatment. Pervasive Developmental Disorders Repetitive stereotyped movements are a characteristic feature of Pervasive Developmental Disorders. Stereotypic Movement Disorder is not diagnosed if the stereotypies are better accounted for by a Pervasive Developmental Disorder. Obsessive-Compulsive Disorder Compulsions in Obsessive-Compulsive Disorder are generally more complex and ritualistic and are performed in response to an obsession or according to rules that must be applied rigidly. Tic Disorders Differentiating the complex movements characteristic of Stereotypic Movement Disorder from simple tics (e.g., eye blinking) is relatively straightforward, but the differential diagnosis with complex motor tics is less clear-cut. In general, stereotyped movements appear to be more driven and intentional, whereas tics have a more involuntary quality and are not rhythmic. Trichotillomania In Trichotillomania, by definition, the repetitive behavior is limited to hair pulling. Factitious Disorder The self-induced injuries in Stereotypic Movement Disorder should be distinguished from Factitious Disorder With Predominantly Physical Signs and Symptoms, in which the motivation of the self-injury is to assume the sick role. Psychotic Disorders and Personality Disorders Self-mutilation associated with certain Psychotic Disorders and Personality Disorders is premeditated, complex, and sporadic and has a meaning for the individual within the context of the underlying, severe mental disorder (e.g., is the result of delusional thinking). Neurological conditions Involuntary movements associated with neurological conditions (such as Huntington's disease) usually follow a typical pattern, and the signs and symptoms of the neurological condition are present. Self-stimulatory behaviors Developmentally appropriate self-stimulatory behaviors in young children (e.g., thumb sucking, rocking, and head banging) are usually self-limited and rarely result in tissue damage requiring treatment. Self-stimulatory behaviors in individuals with sensory deficit (e.g., blindness) usually do not result in dysfunction or in self-injury. DSM-5 Diagnostic Criteria A'''. Repetitive, seemingly driven, and apparently purposeless motor behavior (e.g., hand shaking or waving, body rocking, head banging, self-biting, hitting own body). '''B. The repetitive motor behavior interferes with social, academic, or other activities and may result in self-injury. C'''. Onset is in the early developmental period. '''D. The repetitive motor behavior is not attributable to the physiological effects of a substance or neurological condition and is not better explained by another neurodevelopmental disorder or mental disorder (e.g., trichotillomania [hair-pulling disorder], obsessive-compulsive disorder). Specify if: * With self-injurious behavior (or behavior that would result in an injury if preventative measure were not used) * Without self-injurious behavior Specify if: * Associated with a known medical or genetic condition, neurodevelopmental disorder, or environmental factor (e.g., Lesch-Nyhan syndrome, intellectual disability developmental disorder, intrauterine alcohol exposure) * Note: Identify the associated medical or genetic condition, or neurodevelopmental disorder. Specify current severity: * Mild: Symptoms are easily suppressed by sensory stimulus or distraction. * Moderate: Symptoms require explicit protective measures and behavioral modification. * Severe: Continuous monitoring and protective measures are required to prevent serious injury. Recording Procedures For stereotypic movement disorder that is associated with a known medical or genetic condition, neurodevelopmental disorder, or environmental factor, record stereotypical movement disorder associated with (name of condition, disorder, or factor) (e.g., stereotypic movement disorder associated with Lesch-Nyhan syndrome). Specifiers The severity of non-self-injurious stereotypic movements ranges from mild presentations that are easily suppressed by a sensory stimulus or distraction to continuous movements that markedly interfere with all activities of daily living. Self-injurious behaviors range in severity along various dimensions, including the frequency, impact on adaptive functioning, and severity of bodily injury (from mild bruising or erythema from hitting hand against body, to lacerations or amputation of digits, to retinal detachment from head banging). Differential Diagnosis Normal development Simple stereotypic movements are common in infancy and early childhood. Rocking may occur in the transition from sleep to awake, a behavior that usually resolves with age. Complex stereotypies are less common in typically developing children and can usually be suppressed by distraction or sensory stimulation. The individual's daily routine is rarely affected, and the movements generally do not cause the child distress. The diagnosis would not be appropriate in these circumstances. Autism spectrum disorder Stereotypic movements may be a presenting symptom of autism spectrum disorder and should be considered when repetitive movements and behaviors are being evaluated. Deficits of social communication and reciprocity manifesting in autism spectrum disorder are generally absent in stereotypic movement disorder, and thus social interaction, social communication, and rigid repetitive behaviors and interests are distinguishing features. When autism spectrum disorder is present, stereotypic movement disorder is diagnosed only when there is self-injury or when the stereotypic behaviors are sufficiently severe to become a focus of treatment. Tic disorders Typically, stereotypies have an earlier age at onset (before 3 years) than do tics, which have a mean age at onset of 5-7 years. They are consistent and fixed in their pattern or topography compared with tics, which are variable in their presentation. Stereotypies may involve arms, hands, or the entire body, while tics commonly involve eyes, face, head, and shoulders. Stereotypies are more fixed, rhythmic, and prolonged in duration than tics, which, generally, are brief, rapid, random, and fluctuating. Tics and stereotypic movements are both reduced by distraction. Obsessive-compulsive and related disorders Stereotypic movement disorder is distinguished from obsessive-compulsive disorder (OCD) by the absence of obsessions, as well as by the nature of the repetitive behaviors. In OCD the individual feels driven to perform repetitive behaviors in response to an obsession or according to rules that must be applied rigidly, whereas in stereotypic movement disorder the behaviors are seemingly driven but apparently purposeless. Trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder are characterized by body-focused repetitive behaviors (i.e., hair pulling and skin picking) that may be seemingly driven but that are not apparently purposeless, and that may not be patterned or rhythmical. Futhermore, onset in trichotillomania and excoriation disorder is not typically in the early developmental period, but rather around puberty or later. Other neurological and medical conditions The diagnosis of stereotypic movements requires the exclusion of habits, mannerisms, paroxysmal dyskinesias, and benign hereditary chorea. A neurological history and examination are required to assess features suggestive of other disorders, such as myoclonus, dystonia, tics, and chorea. Involuntary movements associated with a neurological condition may be distinguished by their signs and symptoms. For example, repetitive, stereotypic movements in tardive dyskinesia can be distinguished by a history of chronic neuroleptic use and characteristic oral or facial dyskinesia or irregular trunk or limb movements. These types of movements do not result in self-injury. A diagnosis of stereotypic movement disorder is not appropriate for repetitive skin picking or scratching associated with amphetamine intoxication or abuse (e.g., patients are diagnosed with substance/medication-induced obsessive-compulsive and related disorder) and repetitive choreoathetoid movements associated with other neurological disorders.